The First Tracheostomy

 

During their Master of Surgery (MS) in Surgery postgraduate course, the junior residents of the Surgery department of AIIMS, New Delhi are posted for few months in the department of neurosurgery. One of the things which the junior residents used to look forward to during their neurosurgery posting was doing a tracheostomy.

 With the Covid-19 era now everyone knows about the tracheal tube inserted from the mouth if a patient is not able to breathe on his own and artificial respiration given by ventilators. If a patient requires a tracheal tube and ventilator support for a long time, then the surgeon makes a direct hole (incision) in the front part of the neck, exposes the trachea (windpipe), and inserts a tube directly in the trachea through it known as tracheostomy or tracheotomy.

Due to prolonged coma, there used to be many patients in the Neurosurgery department who used to require tracheal tube and ventilator support for a long time. The operation of tracheostomy was usually entrusted to the Neurosurgery Mch senior residents, who in turn used to teach the general surgery junior residents to do it. After some experience, the junior residents starts doing it independently without supervision, so that the senior resident is free to do some other important work. Most general surgery junior residents used to do their first tracheostomy and later gain mastery of the operation in the neurosurgery department.

After few days of posting the senior resident on night duty called Dr. Dev (Fictional Name), who was on rotation posting during his MS (Surgery) course in AIIMS, New Delhi. He told Dr. Dev that the patient in Neurosurgery ICU A on Bed no 2 requires tracheostomy and he will demonstrate to Dr. Dev how to do a tracheostomy. He also told him that they will do the tracheostomy in the ICU itself as the neurosurgery operation theatre reserved for tracheostomy and other infected operations was closed for repair. The senior resident fixed the time at 4.30 am in the morning.

Usually, there are many patients coming to the emergency department till 2 to 3.00 am and the neurosurgery senior resident used to be busy attending to such patients. There were usually no calls between 3 to 5 am so he will be free to teach Dr. Dev to do the procedure. Also by 5.00 am the operation will be over and both of them can start their respective morning routine work after that.

At 4.30 am Dr. Dev was woken up by the pager calling him to the ICU. As Dev had slept at 2.00 am at night due to ward work, groggy with sleep, barely able to keep his eyes open and stay erect on his feet, he reached the ICU. The Neurosurgery senior resident was already there and so was the anesthetist.

It was the anesthetist's duty to remove the tracheal tube via mouth when the tracheostomy is made and monitor the patient's vital signs such as heart rate, breathing rate, and pattern, O2 saturation, etc. during the operation. The operation theatre (OT) nursing staff had also reached the ICU with their instruments.

Just as Dr. Dev and the senior resident after cleaning their hands and downing their sterile gloves and gowns got ready to do the operation that the senior resident received a call to reach urgently the emergency department. Due to the emergency, the senior resident asked Dr. Dev to start the preliminary part of the operation such as cleaning the skin with disinfection solution, laying sterile sheets around the operation site to avoid infection, and giving local anesthesia injection, while he attends the emergency call and comes back swiftly.

With an anxious heart, Dr. Dev started the initial part of the operation. Before this Dr. Dev had never even seen the tracheostomy operation let alone performed one. Remember, this was before the days of YouTube and internet videos. The only good thing was that as he knew that he will get the opportunity to do a tracheostomy during the neurosurgery posting so he had read in detail about the procedures from the books available in the AIIMS library.

The preliminary part of the operation was now complete but yet there was no sign of the senior resident. The anesthetist asked Dr. Dev, ‘Why are you waiting? Complete the operation fast as the patient is not in a good condition.’ The nursing staff also asked Dr. Dev to start as they had to go back to the operation theatre for their other work. With palpitation in his heart, Dr. Dev made the incision (cut in the skin). He asked for the cautery device to further cut the deeper tissues as there was much bleeding.

In their general surgery OT, they had a monopolar type of cautery device. This was a pen-like device. Using electric current the tip of the device gets heated which then cuts the body tissue at the same time stopping minor bleeding due to the heat. The neurosurgery nursing staff handed him a forceps-like instrument. A surprised Dr. Dev asked what this is as he had never seen such a device ever in his life.

The staff nurse informed Dev that this is a bipolar type of cautery forceps and only this was used in neurosurgery OT. Unlike the pen-like direct action of the monopolar device, here you have to cut the tissue first with a surgical knife or scissor, and then to control bleeding you pinch the bleeding site with these forceps then activate the machine to heat the tissues. So now, in addition to doing the operation of the tracheostomy first time alone, without assistance, Dr. Dev had to learn how to use the new gadget on his own.

So the sleepy, tired, Dr. Dev using unfamiliar instruments proceeded in the unfamiliar operation, till he reached the trachea/windpipe. Now there was no turning back. Dr. Dev made the hole in the trachea, asked the anesthetist to quickly remove the tracheal tube from the mouth and he swiftly inserted the direct tracheostomy tube in the new opening. With the crucial part of the operation now over, Dr. Dev found new energy and confidence and rapidly sutured the tissues and skin around the tube, and asked for the dressing to apply around the wound. As he handed over the patient back to the anesthetist and ICU nursing staff for further care, he prayed that the OT nurse and anesthetist had not noticed how tense and apprehensive he was when he started the operation.

Even when you are sure that you will be playing the part of just an assistant or of being guided in some new activity, it is better to be prepared to take over independently if the opportunity presents itself.

One should not assume about the facility or instruments one will be getting in a new place or situation but should find out in detail beforehand. Not just in an operation but even in a simple thing such as lecture or presentation, we see people struggling with an unfamiliar computer system, mike, pointer device, etc. So go beforehand and find out what exact tools or facility you will be getting in a new or unfamiliar setup or place.

— ND

(Based on allegedly true incidents.)

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal, and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal, and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board norms.